Both the 1995 and 1997 Evaluation and Management Documentation Guidelines define a review of systems (ROS) as an account of body systems obtained through a series of questions seeking to spot signs and symptoms that the patient may be experiencing, or has experienced. This query is made by the physician and/or the staffs verbally, or via a patient intake form, to define the patient’s total problem. It includes defining the need for an extended examination, testing, and possible effective management options. Review of systems should be medically necessary. It may be considered necessary to obtain a complete ROS when a patient presents as an initial new patient. It may not be considered medically necessary to repeat that complete review on every follow up. For purposes of review of systems, the following 14 systems are recognized.
There are four levels of history which are referenced by the CPT® code book, but there are three types of review of systems:
Know Review of Systems for More Accurate Coding was last modified: February 6th, 2019 by
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